The newsletter intensetimes has been created to provide members of the intensive care community with topical and timely commentaries on their sphere of medicine, especially matters connected with sedation, analgesia and anaesthesia. The aim is to compile a mixture of reports from congresses, expert reviews, literature scrutiny, and articles that address the interests and concerns of practitioners in this sophisticated and demanding arena of critical care medicine.

Welcome to issue 10 of intensetimes. In this Summer issue 2010, Dr David Gozal and Dr Keira Mason have contributed an essay entitled 'Paediatric sedation: a global challenge'. In order to ensure that we give proper place in our print offering to an invited essay of exceptional scope and density, part of the lead essay has been included as supplementary material available only on this website. Please click here to see this additional material.

Issue 10 of intensetimes also contains reports from the 2010 meeting of the European Society of Anaesthesia (Euroanaesthesia 2010). As the intellectual content of Euroanaesthesia 2010 was as extensive as ever, we have been forced to omit much that was worthy of inclusion. Some of this material, however, we have managed to retain and have made available to our readers as supplementary material. Again, please see the link below to access this additional material.

Click on the links below for Supplementary material from ESA available with issue 10 of intensetimes.

Choose your own language edition here:

Read more congress highlights here

More from ISICEM 2010 – Unmet needs in ICU sedation

What is the right dose for music therapy?

Professor Mervyn Singer (London, UK), the first speaker at the ISICEM satellite symposium ‘Unmet needs in sedation’, identified a range of obstacles to the delivery of ICU sedation. These included:

a weak evidence base for best practice (reflected in marked variations in practice)*
confusion about the uses of individual drugs and their place in the sedation repertoire
sub-optimal use of drugs in combination.

Underlying these signs of confusion was a true confusion, according to Professor Singer: there is not a robust consensus about the aims of sedation and therefore no robust consensus on how to practise sedation day to day.

*See, e.g., O’Connor M et al. Am J Crit Care 2009 Sep 21 [Epub ahead of print]; Egerod I et al. Intensive Care Med 2006;32:60–6; Martin J et al. Intensive Care Med 2006;32:1137–42.

Sedation: keep it light and get personal

Deep sedation has its place but it is not needed for every patient. Professor Singer identified numerous undesirable consequences of excessively deep or excessively prolonged sedation, including risk of muscle wasting (ICU-acquired weakness), need for mechanical ventilation (and prolonged weaning from ventilation), heightened risk of secondary infections, delirium and longer-term neurocognitive and psychiatric problems. He acknowledged that daily sedation stops (without or with spontaneous breathing trials [see, e.g., Kress JP et al. NEJM 2000;342:1471–7; Girard TD et al. Lancet 2008;371:126–34]) for clinical assessment, with the option of restarting sedative drugs (with dose amended according to clinical need), represented an important advance in sedation technique but argued that there was still scope for substantial improvements in sedation practice. He argued that the general objectives of sedation should be to keep the patient comfortable and pain-free but easily roused. Professor Singer’s proposals for achieving this goal involved creating sedation programmes personalized to the needs of individual patients and including:

depth of sedation to be scored every hour
titration of drugs according to the results of the sedation scoring
use of non-pharmacological measures to promote patient comfort and tranquillity.

Before embarking on any programme of sedation it is essential to assess both the true circumstances of the patient and the goals of treatment. Noting that the proper response to pain is pain relief, which is not at all the same as sedation, Professor Singer outlined a simple pathway for the clinical assessment of an agitated patient that can be used to guide drug choice (Figure).

Notes

Pain relief is first consideration: options include opiates, alpha2-agonists
Consider additional needs

patient requires ‘heavy’ sedation? (e.g. for brain protection or mechanical ventilation): options include: benzodiazepine, propofol, opioids
patient requires calming but not ‘heavy’ sedation? Options include: haloperidol, alpha2-agonists

Use non-pharmacological methods: e.g. verbal and tactile soothing, good sleep pattern, noise reduction, mobilization, presence of family/friends

Use of scales to quantify depth of sedation was identified as a critical change to practice by Professor Singer. He advised that regular routine and systematic use of a scale was far more important than a long debate about which scale to use.

A presumption in favour of less deep sedation implies lower dosages of sedative drugs. Professor Singer noted several benefits from such a policy, including lessened potential for vasoactive and immunological effects** and faster (and by implication easier) weaning. Reducing the time patients spent in the ‘twilight zone’ of deeper sedation is generally more congenial for the patient and their family, and usually also for the staff (even though it may have consequences for workload).

**See, e.g., Song HK & Jeong DC. Anesth Analg 2004;98:1724–8; Brand JM et al. Shock 2003;20:213–7; Brand JM et al. J Interferon Cytokine Res 2001;21:793–6. See also the lead essay in issue 9 of intensetimes which may be downloaded by clicking here.

The hazards of ICU-related delirium and post-traumatic stress disorder (PTSD) were highlighted by Professor Singer: these are, he acknowledged, easy to overlook in the ICU, where longer-term contact with patients is often slight. He considered, however, that these experiences can have an important impact on patients (see, e.g., MacLullich AM et al. Int Rev Psychiatry 2009;21:30–42; Hopkins RO & Brett S. Curr Opin Crit Care 2005;11:369–75). These considerations may shape the choice of sedative agent (see, e.g., Pandharipande PP et al. JAMA 2007;298:2644–53) or sedation strategy (see, e.g., Strøm T et al. Lancet 2010;375:475–80).

A good sleep can help

Professor Jean Mantz examined whether sleep disruption and delirium, both of which affect many ICU patients, are interconnected, and their possible impact on longer-term cognitive decline.

Professor Mantz was convinced that delirium is highly deleterious to the prognosis of ICU patients (see Ely EW et al. JAMA 2004;291:1753–62) and that it is substantially under-recognized in that setting (Cheung CZ et al. Intensive Care Med 2008;34:437–46). Echoing some views of Professor Singer, he advocated regular use of delirium assessment scales to improve recognition of the condition; his own preference, based on work such as that of Luetz A et al. (Crit Care Med 2010;38:409–18) was for the CAM-ICU (Ely EW et al. Crit Care Med 2001;29:1370-9). Professor Mantz was also strongly supportive of the proposals by Luetz et al. for a systematic and practical approach to monitoring for delirium.*

*The full algorithm appears in issue 9 of intensetimes which may be downloaded by clicking here.

Older patients are especially at risk for delirium; in these often frail patients it is especially important to investigate and correct organic causes of delirium, including sepsis, advised Professor Mantz. He illustrated this advice with a case study of an elderly woman whose postoperative delirium was traced to an intestinal abscess: the ‘cure for delirium’ in this case was laparotomy and antibiotics, not an antipsychotic drug. As to the general status of antipsychotics, Professor Mantz acknowledged their value but was not convinced that there was a case for the indiscriminate use of these agents. He commented that delirium may well consist of reversible and irreversible components, and that while antipsychotics may influence the first element they probably do not affect the second (implicit in this portrayal of delirium was the idea that prevention may be preferable to treatment).

Disruption to sleep has also been linked to complications and poor outcomes in ICU patients, as well as to an extensive range of cellular and biochemical effects (see, e.g., Friese RS. Crit Care Med 2008;367:697–705; Dispersyn G et al. Anesthesiology 2010;112;335–7; Gabor JY et al. Am J Respir Crit Care Med 2003;167:708–15; Roche Campo F et al. Crit Care Med 2010;38:477–85). Disturbance of melatonin secretion has been reported in ICU patients: this may be relevant to sleep disturbance (Perras B et al. Intensive Care Med 2007;33:1954–8).

Whether or not sleep and delirium are interrelated is for the moment an unresolved question. Professor Mantz noted that there are at least three theories about the causes of delirium that might be relevant also to disruption of sleep: (a) abnormalities of tryptophan metabolism; (b) ischaemia; and (c) imbalance between excitatory and inhibitory neurotransmitter systems (see Figueroa-Ramos MI et al. Intensive Care Med 2009;35:781–95). But, as Professor Mantz admitted, there is no conclusive evidence for a causal connection via these pathways. On the practical, clinical side of the argument, however, he identified four recent clinical studies in which either disturbance of sleep, correction of sleep disturbance or pharmacological preservation of normal sleep may had have a bearing on the reported incidence of delirium (Schweickert WD et al. Lancet 2009;373:1874–82; idem 2010;375:475–80; Pandharipande PP et al. JAMA 2007;298:2644–53; Riker RR et al. JAMA 2009;301:489–99).

Other practical considerations identified by Professor Mantz include the differing impact of mode of ventilation on sleep. Specifically, both proportional assist ventilation and assist control ventilation appear to deliver better sleep and perception of sleep than pressure support ventilation (Alexopolou C et al. Intensive Care Med 2007;33:1139–47; Toublanc B et al. Intensive Care Med 2007;33:1148–54). Professor Mantz thought that these possibilities deserve more systematic investigation.

In addition to appropriate selection of sedative (preferably a single agent) and optimized ventilator set-up, Professor Mantz regarded sleep-promoting modifications to the ICU environment as very important to the general welfare of patients.

The nurse contribution to patient comfort in the ICU was examined by Professor Sanna Salanterä (Turku, Finland) under the headings of identifying risks, good basic care, environment and follow-up.

Professor Salanterä started by reminding her audience that knowing the patient matters – a lot. Personal circumstances, emotional state, positive or negative previous experiences of hospitalization and health habits (e.g. smoking or other forms of substance abuse) can all have important impacts on patients’ experience of the ICU.

On the subject of pain, Professor Salanterä asserted that the severity of pain experienced by ICU patients is often underestimated and that unrelieved pain can contribute to loss of sleep and deterioration of sleep quality, disorientation and exhaustion, in addition to the immediate suffering. She was thus fully convinced that pain has to be detected, assessed, managed, evaluated and documented, and that if this is done consistently and efficiently it provides the basis for a system of analgesia that is responsive to the needs of individual patients and which can deliver supplementary benefits, such as reductions in the duration of mechanical ventilation and in the number of secondary infections.

Like her colleagues on the symposium faculty, Professor Salanterä believed that a commitment to the regular and systematic use of a pain rating scale was more important in the delivery of analgesia than arguing about which of the available scales might be in some sense ‘the best’. Her own research in this area (Pudas-Tähkä SM et al. J Adv Nurs 2009;65:946–56) led Professor Salanterä to the view that any of the three most widely used pain scales (Behavioral Pain Scale, Non-Verbal Pain Scale, Critical Care Pain Observation Tool) was a satisfactory instrument for this purpose. Drawing again on some of her own recent research (Axelin A et al. Eur J Pain 2009 Dec 15 [Epub ahead of print]), Professor Salanterä also had a highly provocative view on the possible adverse effects of opioid (specifically oxycodone) analgesia. Salanterä and colleagues used polysomnography to study the effects of pain and pain management on the sleep of preterm infants. They found that procedure-related pain was associated with a reduction in REM sleep regardless of pain management (p<0.001). In addition, however, they observed that use of oxycodone was associated with a substantial further reduction in REM sleep. The researchers expressed concern that such large reductions in the quantity of REM sleep may have consequences for brain development in preterm infants. Professor Salanterä was concerned that similar effects might also apply to adults and urged further study of this possibility.

Nursing care may also make a big difference to the risk of delirium, noted Professor Salanterä, by acting on modifiable risk factors such as the disorientation that comes from having no clear sense of time, no access to visible daylight, intubation (and hence severe restrictions on the ability to communicate*) and other matters that contribute to a sense of isolation and depersonalization. (Nursing care of aspects of acute illness may also be beneficial in reducing risk of delirium.)

*This is of special importance because one of the major communication needs of patients is to draw attention to pain.

Good basic care is, suggested Professor Salanterä, an underemphasized service to ICU patients. This may in part reflect a lack of systematic research in this area. However, a meta-analysis is probably not essential to support the idea that attention to personal hygiene will benefit most patients. For example, simple and low-cost oral care can reduce rates of ventilator-associated pneumonia (VAP) in surgical ICUs (Sona CS et al. J Intensive Care Med 2009;24:54-62). This sort of practice, nevertheless, appears not to be widely in place (DeKeyser Ganz F et al. J Nurs Scholarsh 2009;41:132–8). Professor Salanterä recommended tooth-brushing twice a day with a soft toothbrush and moisturizing oral mucosa and lips every 2–4 h. She also thought it desirable that all patients should have an individual activity programme, but acknowledged that here again robust evidence to guide practice is scarce. The same is true of positioning: it is accepted that prone positioning improves pulmonary gas exchange for patients with acute respiratory distress syndrome, but the proposition that head-of-bed elevation prevents VAP is compromised by the lack of any clear evidence of what might be the optimal angle for that purpose. Similarly, it was Professor Salanterä’s view that there is no compelling evidence in favour of the practice of repositioning of the patient every 2 h (Johnson KL & Meyenburg T. AACN Adv Crit Care 2009;20:228–40).*

*Professor Salantera fully endorsed the principle of moving patients to prevent the development of pressure sores: her point, used to illustrate a general lack of robust evidence in this area, was that the choice of a 2h interval is largely arbitrary.

There is a similar lack of data about the value and impact of changes to the environment of the ICU, reported Professor Salanterä. She added, however, that given the numerous, intrusive and quite often hostile-seeming range of noises that assault a patient in the ICU (e.g. alarms, ventilators, other patients, emergency situations, conversations about them but not involving them, ringing telephones, etc.) it seems likely that some relief from noise will benefit many patients – provided it is not taken too far and does not result in patients becoming isolated. Sound dampening, acoustic absorption and changes to general behaviour in the ICU were among Professor Salanterä’s suggestions for reducing noise-related stress. Sound masking is another possibility and music may be used for that purpose. Professor Salanterä cautioned, however, that despite some objective data for the efficacy of music to relieve anxiety in mechanically ventilated patients (Chlan L. Arch Psychiatr Nurs 2009;23:177–9), the use of music in the ICU cannot be regarded as a ‘no-brainer’. Individuals’ emotional responses to music can be very strong and for some people being confined with what they regard as the wrong sort of music is a private version of hell. There is, moreover, no indication of what might be the right ‘dose’ of music.

From a nursing perspective, surprisingly little is clear about the impact (if any) of circadian rhythms and disruption to those rhythms. Areas identified by Professor Salanterä as needing more formal investigation included:

should ICUs try to separate day and night?
how much sleep does the patient need and actually get?
How, individually, are nursing interventions planned?

Looking beyond the ICU, Professor Salanterä endorsed the idea that there needs to be greater engagement of nurses with patients’ longer-term progress. Areas for research include assessment of the best ways of ‘debriefing’ patients after discharge and health-related quality of life.

From ESICM 2008 - How long have we been flying?

If you are a civilian pilot, the answer to that question is .never more than 10 hours.. We can be certain of that because the limit of 10 hours flying between two stops is specified in law and strictly enforced.

By contrast, as Dr Philip Metnitz (Austria) noted, if you work in an ICU the answer may often involve a number much larger than 10. EU regulations currently tolerate doctors working (with the agreement of the hospital) up to 32 h a week in a single shift. There is, according to Dr Metnitz, every reason to suggest that the responsibilities of ICU doctors are as significant and demanding as those borne by pilots, and a correspondingly strong case for suggesting to legislators that the regulations governing doctors. hours of work reflect that similarity by ensuring a better balance between work, education and training, and private time.

Dr Metnitz. comments were part of a debate about staffing resources for ICUs. Notwithstanding the efforts of a distinguished faculty to ground this debate in numbers, this was a session that moved firmly towards reflections on the philosophy of medicine and the nature of responsibility, and which examined some of the ways in which traditional models are adapting . or may have to adapt . in order to meet modern circumstances.

So, how many doctors is the .right. number of doctors for an ICU? The ESICM recommendations of 1997 proposed five per 6.8 ICU beds. A show of hands among the audience revealed only ~20% consider their own ICU currently meets this goal.* Dr Metnitz preferred, however, a qualitative answer to this question: he proposed that the right number of doctors is the one that allows for a workload that balances experience with well-being. The goal should be to create opportunities for good training while avoiding an unnecessary increase in adverse events (brought about by lapses in information transfer between shifts).

Despite doctors. lack of parity in law with pilots, there are indications that the initial adaptations to the European Working Time Directive (EWTD) have had a positive impact on patient outcomes, such as the reduction in re-admissions reported by Frankel and colleagues (J Trauma 2006;61:116-21). Dr Metnitz was also confident that ICUs need not just more doctors but more specialist doctors. He acknowledged, however, that the objective evidence for the first of those views was surprisingly slender. The meta-analysis by Pronovost, Angus and colleagues (JAMA 2002;288:2151-62). is the best collection of evidence for this point of view, but the fact that a meta-analysis is necessary provides an early warning that the volume of good-quality data on this point may not be as extensive as might be imagined. Moreover, although that exercise certainly related better patient survival and shorter duration of stay to higher intensity staffing, the key word here is staffing, a term that involves more than just the number of doctors. There is also the very recent work of Levy et al., which appears to entirely confound the notion that more doctors means better outcomes in ICU (Ann Intern Med 2008;148:801-9). The size of the database used in this research. more than 100,000 adult patients in 123 ICUs across the USA . makes these data difficult to ignore. Interpretation is another matter, and Levy et al. themselves acknowledge that they have as yet no explanation for these findings. Nevertheless, these findings are a timely caution against the danger of assuming that more staff invariably means better outcomes.

The emphasis on the desirability of increasing the numbers of specialist doctors in ICUs highlighted another point: what exactly constitutes a specialist? The meaning of that term currently varies widely and complicates the investigation of the impact of more .specialists... However, in exchanges between Dr Metnitz and the audience, Professor Julian Bion (UK) advised that CoBaTrIce, the ESICM programme for competency-based training in intensive care medicine in Europe (www.cobatrice.org), has now produced a .product specification. or definition of an intensivist. This, Professor Bion suggested, was an essential first step in finding out whether such physicians really make a difference to ICU performance. Research into this clearly important matter may be expected to gather pace in coming years.

The benefits to patients of a low nurse:patient ratio (defined as not more than 1:2) have been documented (Dimick JB et al. Am J Crit Care 2001;10:376-82) but that does not necessarily help to specify what constitutes .enough. nurses (beyond the obvious answer of more than we have at present!). According to Professor Rui Moreno (Portugal), answering that question . which must be done on a unit-by-unit basis . involves deriving quantitative estimates of: .the nursing work capacity of a unit (based on current staff levels) and .the efficiency with which nursing work capacity is deployed.

Professor Moreno stressed that although some of these calculations could seem abstruse, they were important: nursing power is the single most costly resource of many ICUs so it is important that it is used well. It probably is no accident that the first instrument to examine this aspect of ICU staff resourcing (the Therapeutic Intervention Scoring System; TISS) is already more than a quarter of a century old (Silverman DG et al Crit Care Med 1975;3:222-5).

Studies of .efficiency of deployment. indices such as the work utilitization ratio (WUR; see Panel) reveal spectacular variations both within and between countries. Identifying units with either very low WURs (implying inefficient use of costly and skilled staff) or high WURs (i.e. consistently >1, suggesting nurses are being overworked with consequent risk of errors) is the first step towards a more efficient (and hence sustainable) use of resources.

An important practical point to emerge from these technical reflections was that in many instances nurse workload is a function of the quantity of care delivered more than the complexity of care. A corollary of this remarked upon by Professor Moreno was that when, as is the case in many units, staffing levels are fixed, a patient arrives whose condition is going to generate a large quantity of care, the systemic response is to offset that increase by restricting or (trying to reduce) unit occupancy. Given what is known about the relation between occupancy rate at time of admission and outcome, that response may well be in the interests of subsequent patients.

The EWTD has made shift-work inevitable in medicine, which, given the ample evidence that working hugely extended hours is bad for the health both of junior doctors and for the patients they care for (see for example Barger LK et al N Engl J Med 2005;352:125-34, and Boivin DB Sleep Med 2007;8:578-589) is probably a very good thing for all concerned. A shift length of 9 h appears to be about the limit for minimizing risk of fatigue-related errors. However, as Professor Bion considered in a scheduled presentation, the practical recognition of this fact in scheduling the hours of doctors, and in particular specialist trainees, may have profound consequences for the doctor.patient relationship and for doctors. experience of medical training.

First, it means that a doctor.s responsibility to a patient . once perhaps considered limitless in theory . will now be governed by the clock to the extent that hospital and healthcare systems may even decline to defend errors made by a doctor who was worked past the end of his/her shift. In addition, mandatory education constitutes work and must therefore be delivered during specified working time, not fitted around clinical activities. That, in turn, marks a shift from medical training as a form of apprenticeship, in which the trainee is constantly at the behest of a senior physician/patron, to one of formal structured learning.

Less time at work for doctors will also mean a greater emphasis on team-working. This, too, will change the nature and quality of the doctor.patient relationship, shifting the historical personal responsibility of the doctor to a group of people who will have to discharge that responsibility as a collective and as individuals. Negotiating that shift with some patients will require care and dexterity. In addition, and this may prove to be one of the biggest challenges thrown up by the EWTD, there is a dominant need for consistent and well-integrated methods for transmitting information between shift teams.

Professor Bion had some encouraging words for those who regard these changes as difficult or problematic. While appearing to make medicine less of a profession and more of a job, some of the first effects of these changes may, in fact, have been to bring new lustre to the old concept of esprit de corps. For example, there is an obvious threat to time devoted to education if education has to take place in on-shift time. Early evidence from the UK, which has applied the EWTD widely, suggests, however, that this concern may not always be justified. One of the biggest determinants of whether education time is protected appears to be the attitudes of individual consultants (Lee E et al. Eur J Cardiothoracic Surg 2006;30:574-577). Similarly, good-quality supervision appears to have powerful positive effects on juniors. confidence in their ability to cope with the necessary and inevitable pressures of their position. That those pressures exist and that they can lead to depression and burn-out is clear, even if the factors leading to those outcomes can be surprisingly hard to identify in formal studies (Fahrenkopf AM et al, BMJ 2008;336:488-491). It was Professor Bion.s strongly expressed view that the mental health of everyone in an ICU team is of the utmost importance and that how the members of a team care for their own mental health and the mental health of colleagues is a major factor in the creation of a harmonious and effective unit that can rise to the challenges of its work.

ESICM 2008, 22 September Session: Staff requirements in the ICU

Legal and philosophical views on the end-of-life

Not every patient who enters an ICU is going to pull through. What to do (and how to do it) for those at the ends of their lives was the subject of an ESICM session that examined the philosophical and legal arrangements in places in different parts of the world. A great deal of carefully considered thought was on display during this debate: lack of space prevents intensetimes giving a comprehensive account of the exchanges, but we hope this short report will go some way to illustrating how societies around the world address this vital matter, while also illustrating that although these societies all approach the matter from a principled moral position the expression of those principles can differ markedly from place to place.

One view shared by the faculty at this session was that unless operating in a country where active euthanasia is recognized and permitted in law* this term, along with phrases such as .passive euthanasia., .assisted suicide. and .mercy killing. should be avoided. Leaving aside for a moment that these activities are expressly forbidden in most jurisdictions and punishable by heavy jail sentences, these terms are hugely emotive, deeply confusing and have the potential to poison any serious discussion on how to respond to a patient in terminal decline.

Other salient points to emerge from the discussion were the competing concepts of the autonomy model (favoured in the USA) and the (benign) paternalism model that predominates in many European societies. In addition, there was the striking example of the Confucian world-view, which shapes the thinking of many Chinese and which owes nothing to either of the two other models.

The legal situation in Israel
First to speak at this session was Professor Charles L Sprung (Israel). This was appropriate as Israel was the first (and is probably still the only) country to have enshrined in law the right of every citizen to palliative care. This right is contained in the Dying Patients Act,** which was passed into law in December 2005. This Law, derived in the first instance from a lengthy expert consensus process, provides for advance medical directives, the appointment of surrogate decision-makers and the incorporation of family submissions into decision-making. It also provides medical practitioners with clear guidance as to what is permissible and what is prohibited.

Fundamental assumptions underpinning the Law include: .Most people do not want to suffer at the end of life (EOL) and do not want their lives prolonged artificially. .There should be a balance between the value of life and the principle of autonomy, interpreted in ways consistent with the particular societal values of Israel. .Every adult is assumed to be competent unless proved otherwise. .Everyone is assumed to want go on living unless proven otherwise; where there is reasonable doubt, medicine must act in favour of life. .Decisions concerning dying patients should be based upon the patients. medical condition, his/her wishes and his/her degree of suffering.

The challenge for the Israeli thinkers, as for others engaged in similar work elsewhere, was to strike a balance between the sanctity of life and the principle of autonomy. Professor Sprung emphasized that the boundary or point of balance between these competing interests is man-made, debatable and may, on occasions, seem arbitrary to onlookers or those encountering it for the first time. The Law is clear, however, that if the wishes of an autonomous patient are in opposition to the sanctity of life the patient must not be forced to accept treatment against his/her wishes. Conversely, any action that intentionally or actively shortens life is expressly prohibited even if the patient requests them. The endorsement of palliation is founded on the moral requirement to alleviate pain and permits (indeed requires) the use of appropriate drugs even if the principle of double effect means that these agents shorten life.

Transparency of decision-taking is another conspicuous feature of the Act, which requires the appointment of a senior physician to each case and which has established institutional and national ethics committees to deal with appeals without involving the courts.

The need to establish consensus with religious interests means that Israel.s Dying Patient Act contains exceptional provisions to deal with the situation of a continuously ventilated patient. However, the process by which the content of the law was developed may have applications in other counties.

Paternalism in Europe
The current legislative landscape for end-of-life situations in Europe has many similarities with Israel. Professor Bertrand Guichet (France) noted that there is ample case-law to differentiate between killing (strictly forbidden, except in Belgium and The Netherlands) and .letting die.. Similarly, the right of a competent patient to refuse treatment even though they know that to do so means they are likely to die is recognized in most European jurisdictions.

However, withdrawal of life-sustaining interventions remains problematic, not least because of the operation of the .paternalism. model in decision-making. This principle, which in essence assigns to the doctor the final decision about how to proceed, has benevolent intentions: there is research indicating that the families of dying patients . already subject to intense emotional pressure . can be tipped into deep depression or post-traumatic stress disorder by having too much responsibility for decisions to withhold or withdraw care placed upon them (Azoulay E et al. Am J Respir Crit Care Med 2005;171:987-94; see also the report of Robulotta et al. Minerva Anestesiol 2008;74:503.5 for another perspective on attitudes to patient/relative involvement in southern Europe). Several European national expert medical organizations have expressed the views that while the opinions of families may be desirable they are not decisive: this view has been repeated by the International Consensus Conference in Intensive Care. This, in turn, may contribute to marked regional variations in the practice of withdrawing life-sustaining measures, with countries in southern Europe reporting much lower rates of withdrawal than those further north (Sprung CL et al. JAMA 2003;290:790-7). The religious sensibilities of doctors appear to be an influence in this state of affairs (Sprung et al, 2003 idem; Ganz FD et al. J Med Ethics 2006;32:196-9). Similar patterns are seen in the rates of prescription of drugs to hasten death (Crit Care Med 1999;27:1626-33). Considerable heterogeneity of practice is also observed within individual countries (see e.g. Wunch H et al. Intensive Care Med 2005;31:823-831).

"You're dead when the doctor says you are..."

EOL considerations in the huge emerging populations of China and India address the same concerns as in the EU and USA. Development of laws is at an early stage, however, and there are some strikingly different perspectives in play.

No new laws on EOL have been introduced in Hong Kong in recent years: in fact, at present, the only legal definition of death is that you are when a doctor says you are. However, enquiries by the Chinese Ethical Research Survey Group, reported at ESICM by Professor Gavin M Joynt (Hong Kong), suggest that many doctors in China would favour local or national legislation in areas such as do-not-resuscitate (DNR) orders, limitation of therapy and euthanasia. The present limited database suggests that doctors in other parts of China are somewhat less likely than those in Hong Kong or Europe to observe a DNR order and substantially less likely to withdraw therapy or use drugs intentionally to cause death (Yap FHY et al. HK Med J 2004;10:244-50). This seems at variance with doctors. expressed beliefs about legally sanctioned limitation of therapy (LOT) and even euthanasia, which enjoy high levels of support. A reason for these apparently incompatible findings may lie in the role of the family and their interactions with doctors. Doctors in China consider that a high proportion of patients. families are reluctant to consider LOT, whereas a large majority of doctors are uneasy discussing the matter with families.

The role of Confucianism in shaping family priorities may be important here. A central tenet of Confucianism is .filial piety. . the notion that the most important task in life is to repay one.s parents for the burdens they bear. It is also believed that a person cannot become fully human without fulfilling his or her role-specified, relation-oriented responsibilities. However, a sick person may be temporarily relieved of those responsibilities. The operation of the .filial piety. concept then leads to the emergence of a .protector. from among the ranks of the family.* This, in turn, means that the primary axis of an EOL discussion is often between the doctor and the .protector., not the doctor and the patient. This is a model of inter-personal dynamics clearly at variance with both the .autonomy. model and (but for different reasons) the .paternalism. model. Its power is borne out by data showing that, among surveyed doctors in China, 35% considered that when a surrogate is needed to make a decision for a patient that surrogate should be the family only, with the doctor.s role in effect limited to implementing whatever decision the family reaches. As Professor Joynt remarked, .Western. medicine travels with the baggage of Western ethics and moral expectations and these may conflict with established Chinese ethics and moral expectations.

New laws coming in India - slowly

Legislation on EOL management in India is long overdue for reform: current practice is still subject to Articles 306 and 309 of the Indian Penal Code of 1860, which proscribe suicide or the assisting of suicide. Individual legal precedents that appeared to have established exemptions based on compassion have been struck down on appeal. The present situation is such that withdrawal of life-sustaining measures, even in cases of brain death, require a decision by a team of doctors and medical administrators.

The need for laws that reflect modern circumstances has been recognized and a Bill asserting the rights of adult patients to refuse treatment on the basis of informed choice is now before the Indian Parliament. This Bill also re-affirms the prohibition on euthanasia and assisted suicide (which remain criminal offences), but distinguishes between these and the withholding or withdrawal of treatment. The Bill also describes treating patients contrary to their wishes as battery (assault) or, in some cases, culpable homicide. These proposed Indians laws follow the Israeli example in asserting that the principle of sanctity of life must yield to the principle of self-determination. Conversely, the draft legislation nods to the .paternalism. principle in its views on the role of the family in decision-making, a state of affairs that Professor Raj Kumar Mani (India) thought noteworthy (and a little unexpected) in a country with strong notions of the importance of family and kinship. Given the substance and scope of the proposed Bill, and the nature of parliamentary processes, it is not expected that the Bill will be enacted swiftly.

Professor Marcio Soares (Brazil) reported that steps to reform (or create) the legal framework for EOL decisions are also being taken in Brazil, including a proposal (the .Projeto de Lei.) for reform of the Penal Code. These reforms would ensure that withdrawal or withholding of treatment of terminally ill patients would not be crimes and clarify the decision-making process. An obligation to ensure palliative care is also under consideration. Euthanasia and patient-assisted suicides would remain outlawed.

ESICM 2008, 23 Sept Session: New laws on end-of-life decision making

Of human bondage...

An ESICM session with the seemingly innocuous title of "Symptom control" emerged as a forum for discussion of one of the most charged and contentious issues of ICU practice use of physical restraints on patients.

This session was billed as offering oral presentations from two speakers, Ms Julie Benbenishty RN (Israel) and Professor Colin Ferguson (UK). In fact, these discussants collaborated to describe a scenario in which an ICU doctor (implied to be a man) and an ICU nurse (implied to be a woman) disagreed about how to manage agitation (of uncertain cause) in a patient. A central theme brought out during this scenario was the views on the use of physical restraints on such patients.

Contributions from the large audience (n~180) established that there was very little use of (or taste for) restraints and such use as there was subject to formal procedures and recording. It was also affirmed by several contributors that all such practices in ICUs are outlawed in most countries of Scandinavia (exemptions may apply in psychiatry). There was a general presumption throughout this discussion that the use of restraints was being discussed in relation to adult patients.

Leaving aside matters of taste, scruple, ethics and even law, does restraint work? Not according to any evidence Ms Benbenishty had been able to discover. In fact a lot of the evidence points the other way. For example, unplanned intubations, which instinctively suggest should be prevented by restraint, appear not to be, or even to be more frequent in restrained patients: for example, Curry and co-workers found that of 31 patients who self-extubated in a surgical ICU 27 (87%) were subject to restraint at the time of the incident (p<0.001 vs no restraint) (Am J Crit Care 2008;17:45.51). Similarly, Chang et al. have recently reported (Am J Crit Care 2008;17:408.15) that use of restraints increased the risk of unplanned extubation more than threefold in a series of 300 patients in a case-control study in Taiwan.

Even more suggestive is the work of Martin & Mathisen (Am J Crit Care 2005;14:133.42) who studied 50 patients recruited at two ICUs in Norway and 50 other patients accrued from three ICUs in the USA. Unplanned extubations (n=7) occurred only in the US cohort However, patients in Norway were more sedated (p<0.01) and there was a smaller nurse:patient ratio (1.05:1 vs 0.65:1; p<0.001) in the Norwegian units. These data intimate that social, cultural and resourcing considerations may play a part in attitudes to and use of physical restraints (see also Minnick AF et al. J Nurs Scholarsh 2007;39:30.7, who reported wide variations of inter- and intra-institution use of restraints in a large survey in the USA; Demir A. Int Nurs Rev 2007;54:367.74 and J Nurs Scholarsh 2007;39:38.45, who reported on the extent and reasons for use of physical restraint in Turkey, including a high rate of implementation without written instruction or consent in paediatric patients, and deaths ascribable to restraints [also Dube AH, Mitchel AK. JAMA 1986;256:2725.6]; and Yeh SH et al., who reported associations between unplanned intubation and time of day and nurse inexperience [Int J Nurs Stud 2004;41:255.62]).

There are complications of restraint use including strangulation and increased rates of infection and pressure sores. There is also evidence that use of restraints may be associated with longer-term psychological complications. For example, Jones et al. reported that physical restraint with no sedation was one factor linked to the development of post-traumatic stress disorder (Intensive Care Med 2007;33:978.85). Delirium diagnosed on performance in the CAM-ICU questionnaire has been reported to be associated with a greater use of restraints (Micek ST et al. Crit Care Med 2005;33:1260.5; download issue 6 of intensetimes for more from ESICM about CAM-ICU and delirium). However, it is not clear whether use of restraint in this situation affects subsequent outcome.

In many cases the alternative to physical restraint is sedation and this is also not without its risks, especially if a profound level of sedation is targeted. So there may be no easy resolution to this matter. Interestingly, given that the single largest reason for use of restraint appears to be restlessness, a poll of the audience at ESICM indicated a very low use of delirium scales in general, which in theory could be useful for identifying patients whose restlessness may have correctable causes (download issue 6 of intensetimes for more from ESICM about CAM-ICU and delirium).

One potentially highly contentious aspect of this discussion, raised by an audience contributor, is possible differences in outlook between clinical staff and hospital administrators, some of whom may regard restraint as a cheap and easy measure when compared with some of the alternatives. As Professor Ferguson commented, this is just one aspect of a situation that may be described as a power struggle around a patient who has no power. The British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units (Bray K et al. Nurs Crit Care 2004;9:199.212) can be a valuable resource for clinical staff who find themselves in this situation. The new Pan American Consensus report of sedo-analgesia of adults (Celis-Rodríguez E et al. Med Intensiva 2007;31:428-71.) is also cool on the use of restraints, endorsing their use only in appropriate clinical situations and not as a routine procedure (evidence grade 1C).

One other aspect of restraint use examined by Ms Benbenishty is that increasing nurses. knowledge about restraint can lead to changes in practice (implied to mean more selective use of restraints). Recent experience in Canada, in response to new laws designed to minimize use of restraint, suggests that educational initiatives and the introduction of decision-making aids can indeed materially reduce recourse to restraints (see Hurlock-Chorostecki C, Kielb C. Dynamics 2006;17:12.8 for details of the Ontario .Knot-So-Fast. programme).

ESICM 2008, 23 Sept

Session: Symptom control

Communication insights from Norway

ICU staff in Norway are doing a good job at communicating with patients and are in fact doing better than they themselves think they are.* Dr Hilde Myhren and colleagues at Ulleval University Hospital, Oslo, questioned 225 ICU patients and 145 staff between 2005.7 about communication during the patients. ICU stay. The results of this investigation revealed a generally high level of satisfaction among patients about the quality of their communications with staff: nurses narrowly outpointed doctors in the reported indices of satisfaction. Patient-reported satisfaction scores for interactions with staff were higher than the staff-reported scores.

Both anxiety and depression were more severe (as reflected by scores on the Hospital Anxiety and Depression Scale [HADS]) than in the general population of Norway. Higher anxiety scores correlated with pain and a sense in the patients that they had no control over events in ICU; a more acute or extreme sense of depression correlated with patients not feeling able to express needs or present their own questions.

ESICM 2008, 22 Sept Session: Surviving the ICU: clinician.s perspectives

Editor-in-Chief

Editorial Office

Scientific Advisers

CONTENTS 10/10

DOWNLOAD AS PDF